Reducing COPD Exacerbation Readmissions in a Community-Based
Teaching Hospital
Dawn Waddell, PharmD, BCPS Clinical Pharmacy Manager
Lisa Kingdon, PharmD, BCPS Clinical Pharmacy Specialist
Dawn Waddell Baptist Dawn WaddellMemorial
Hospital - Memphis No Conflicts of Interest
Chronic Obstructive Pulmonary Disease (COPD)
30-day readmission rate remains at 20%
across the country
3rd leading cause of death in the US
Affects close to 30
million Americans
Respir Med 2017;131:6-10.
Objective
• Devise a multi-faceted, multi-disciplinary approach to reduce COPD readmissions
– Current 30-day readmission rate: 25-30%
• Average length of stay on readmission: ~9 days
Inpatient COPD
Exacerbation Management
Smoking Cessation
Counseling
Disease State Education
Inhaler Technique Education
Improve Access to
Outpatient Inhalers
Inpatient COPD Exacerbation Care
• Conducted a MUE to evaluate current inpatient prescribing patterns:
Average length of steroid therapy:
3.9 days
Average amount received:
435 mg prednisone equivalents
45% IV Steroids 21% PO Steroids 15% both IV & PO
Average amount of prednisone
equivalents/day:
109 mg/day
Inpatient COPD Exacerbation Care
• Conducted a MUE to evaluate current inpatient prescribing patterns:
Average length of steroid therapy:
3.9 days
Average amount received:
435 mg prednisone equivalents
45% IV Steroids 21% PO Steroids 15% both IV & PO
Average amount of prednisone
equivalents/day:
109 mg/day
Guideline recommendation: Prednisone 40 mg PO daily x 5 days
Outpatient COPD Management
32% of patients discharged with
systemic steroids
Average length of steroid treatment:
12 days
Average amount:
25 mg of prednisone equivalents per day
14% of patients were discharged on
guideline-recommended inhalers
15% of patients filled inhalers prescribed at
discharge
New Inpatient Protocol
Steroids: Old Protocol
o Methylprednisolone 40 mg IV q8h
o Prednisone 40 mg PO daily
Steroids: New Protocol
o Prednisone 40 mg PO daily for 5 days
o Methylprednisolone 40 mg IV q8h for 72 hours then Prednisone 40 mg PO daily – Consider for patients who are
mechanically ventilated, critically ill, or receive systemic corticosteroids as an outpatient
Smoking Cessation Counseling
• Consults were being placed, but there was not any follow through
• Respiratory therapy (RT) designed a new workflow to incorporate counseling and documentation into the flowsheet
• Both physicians and pharmacists are able to place a “RT Smoking” consult
Disease State Education
• Non-adherence to inhaled and oral medications in COPD patients reported to be 41.3-57%
• Effective Interventions
– Brief counseling
– Monitoring & feedback about inhaler use
– Self-management of symptoms
• Cochrane Review evaluation of Action plans
– For every 19 provided action plans, one person would avoid a hospital stay for an exacerbation
Respiratory Research. 2013;14(109): 1-8. Cochrane Database of Systematic Reviews. 2016;12: CD005074.
Inhaler Technique Training
• One page education sheets created – www.use-inhalers.com
• Placebo inhalers obtained from drug representatives
• Education completed by the pharmacist with an observed teach back using the placebo inhaler
Barriers to Outpatient Inhalers
Obstacle (n=32) N (%)
No COPD discharge medications 5 (19%)
Did not pick up medications 11 (41%)
Expensive copay 7 (26%)
Prior authorization needed 5 (19%)
Prior authorization not completed 4 (15%)
14% of patients were discharged on
guideline-recommended inhalers
15% of patients filled inhalers prescribed at
discharge
Insurance Information
• Medicare/Medicaid
– Eligible only for free 30 day coupon card
– Unique formularies for each plan
• Commercial Insurance
– Eligible for all coupon cards
• No insurance
– Manufacturer assistance
91%
3%
6%
n=33
Medicare/Medicaid
Commercial
No insurance
“Equivalence” of Long Acting Inhalers
• Extensive literature search and critical evaluation of meta-analyses for LABA, LAMA, LABA/LAMA, and LABA/ICS inhalers
– Similar rates of exacerbation between all LABA inhalers
– Minimal variation found within LAMA inhalers
– No difference found within LABA/LAMA inhalers
– No difference found within LABA/ICS inhalers
Int J Chron Obstruct Pulmon Dis. 2017;12:367-381. Int J Chron Obstruct Pulmon Dis. 2015;10:2495-517. Int J Chron Obstruct Pulmon Dis. 2015;10:1863-81. Int J Chron Obstruct Pulmon Dis. 2014;9:469-79.
P&T Approval
• Proposal: Pharmacists can complete an automatic inhaler switch within same medication class to patient’s outpatient insurance formulary
Approved!
Identification of Patients
• Daily list of admitted patients
– Includes ~100 patients with COPD on problem list
– Ideal for intervening on readmitted patients
• Goal: identify patients on principal admission
– Collaboration with clinical documentation improvement (CDI) nurses who place a working DRG and ICD-10 code for all Medicare inpatients
– Request to Epic Build Team to allow this field to be viewed by pharmacists and physicians
ICD-10 CM Codes for COPD
Code Description
J42 Unspecified chronic bronchitis
J43.0-9 Emphysema
J44.0-9 Chronic obstructive pulmonary disease exacerbation
Codes included in cohort if combined with secondary diagnosis of J44
J96.0-92 Acute respiratory failure
R09.2 Respiratory arrest
Reviewing patients by their ICD-10 CM codes decreased the 100 patients/day to a more accurate 15-20 patients/month with a
true COPD exacerbation.
Review of Patients on Principal Admission
Process of Interventions
Patient Identification by
Working DRG
• Daily evaluation by a pharmacist
Patient evaluation
• Medication history
• Disease state education
• RT consult for smoking cessation
Ensure fill of outpatient inhalers
or change to formulary product
• Inhaler education with placebo
• Medication in hand prior to discharge
Full Interventions Beginning Mar 2018
16.8%
25.0%
8.6%
21.9%
15.4%
12.1%
27.6%
14.6% 18.9% 19.0% 18.5%
13.8%
13.6%
0%
5%
10%
15%
20%
25%
30%
JUN2017
JUL2017
AUG2017
SEP2017
OCT2017
NOV2017
DEC2017
JAN2018
FEB2018
MAR2018
APR2018
MAY2018
COPD ObservedReadmission Rate
Readmission Rate
Future Plans
• Continuation of interventions for patients admitted with COPD exacerbation
• Addition of a 48-72 hour phone call to ensure understanding of inhalers, receipt of inhalers, and use of action plan for symptoms